Community Care Nurses from Home & Health Care Agency Help Patients Stay Healthy and Avoid Re-Admissions

Tim Becker cares for Wilson Cox at home

Community health nurse Tim Becker recently helped Harlem resident Wilson Cox, 73, avoid readmission for a leg condition that had landed him in the hospital twice in two months.

Thanks to his efforts and those of nurses like him, the HHC Health and Home Care team recently achieved its goal of reducing preventable re-hospitalizations by about 3% this year for patients served by the home-care agency.

The achievement won Health and Home Care First Prize for Community Based Services in the HHC Annual Patient Safety Expo this year. The home-care agency helps patients make the transition from the hospital back to their communities. Its approximately 150 full-time nurses, social workers and therapists assist 12,500 patients annually in their homes, a number that has been increasing.

Experts regard re-hospitalization an indicator that a patient was not properly cared for the first time, was released prematurely or had an inadequate transition plan, says Ann Frisch, RN, BSN, MBA, executive director of HHC Health and Home Care, so avoiding it is critical. Moreover, since Oct. 2012, the federal Affordable Care Act has required the Centers for Medicare & Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions.

Health and Home Care has been able to maintain readmission rates below state and national averages. Re-hospitalizations among adult patients served by the agency were down to 22.8% from 26.55%. Educating patients and helping them care for themselves at home is key to that success.

Yet the home “is probably the single most difficult area of health care to deliver in, because the nurses, therapists and aides are out there in the community by themselves,” Ms. Frisch said, in all kinds of neighborhoods and weather.

Dedicated community health nurses like Tim Becker, 53, of Brooklyn make that possible. He helped Mr. Cox, a retired messenger who suffers from diabetes and peripheral artery disease, to get back on his feet after repeated bouts of disabling leg pain.

Mr. Cox, who lives in senior housing was initially admitted to the hospital in June 2013 suffering from severe pain and swelling in his left leg that left him unable to stand. The widower was unable to cook, clean or properly care for himself. He returned to the hospital in mid-July via ambulance.

Nurse Becker was assigned by discharge planners at the hospital and reported to Mr. Cox’s home within 24 hours. The referral, which was reviewed by the discharging doctor, listed all Mr. Cox’s medications, his diet, his activities, and his next scheduled appointment.

The nurse swung into action: “We come in and assess the situation,” he said. “We take vital signs, make sure he has a glucometer to check his sugar and make sure he’s using it. What is he taking for the diabetes and does he have any medication for the pain in his left leg?”

Mr. Becker, who has more than 20 years nursing experience, also arranged for a home aide to come clean and shop for Mr. Cox three times a week.

Mr. Cox was one of the few patients he works with who already had all the necessary equipment and prescriptions, he said. More often his job requires obtaining them. He also helps clients, many with less than a high school education, understand how and why to correctly take medication or follow dietary restrictions.

Mr. Becker arranged for a follow-up appointment at the clinic, where a test revealed that Mr. Cox had a partially blocked artery in his leg. A stent was installed in outpatient surgery in late August that restored blood flow.

“Within days the pain went away in the left leg, the swelling went away and a healthy color came back to his left foot,” he said. Since then, Mr. Cox has avoided re-hospitalization. He is on the mend and able to use a walker.

Mr. Cox said he is grateful. “He has helped me a great deal. Listening to him and doing what he said to do changed my attitude, because I had more or less given up.”